Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Head-On Impact: A Rare Case of Cephalohematoma in Utero Neethi Narasimha, OMS-III 1 , Steven Lewis, MD 2 . 1. Edward Via College of Osteopathic Medicine – Carolinas Campus

Discussion

Visual Aids & Imaging

Introduction

Cephalohematomas are characterized by the accumulation of blood within the subperiosteal space, typically resulting from shearing forces exerted on the skull during delivery. These forces lead to the separation of the periosteum from the calvarium, subsequently disrupting blood vessels and forming a hematoma [1] (Fig. 1). This condition is most associated with prolonged or instrument-assisted vaginal deliveries, with an incidence reported to range from 0.4% to 2.5% of vaginal births [1]. In contrast, data on the occurrence of cephalohematomas in utero remains exceedingly scarce. A review of the literature reveals only three such documented cases of this phenomenon, including this case [3]. A 23-year-old G2P1 female at 36 weeks' gestation presented to the emergency department following a motor vehicle accident, with complaints of right arm and pelvic pain. She was restrained, and airbags deployed on impact. Vital signs were stable, and imaging of the right arm and pelvis revealed no fractures. On examination, she exhibited regular, painful contractions, and fetal heart monitoring showed persistent fetal tachycardia. Bedside ultrasound revealed decreased fetal movement. An emergent cesarean section was performed, delivering a live female infant with an APGAR score of 6 at 1 minute and 7 at 5 minutes. No trauma or placental abruption was noted. Post-delivery, the infant's tachycardia persisted, accompanied by respiratory distress, and she was transferred to the NICU for further management. Physical examination revealed a tender fluid collection over the right parietal skull, though the anterior fontanelles were open, flat, and soft. Neonatal evaluation noted nasal flaring and chest retractions. Relevant labs showed neonatal anemia; other results were unremarkable. A diagnosis of subgaleal hemorrhage was made, and the infant was placed on noninvasive neurally adjusted ventilatory assist (NIV NAVA). Head x-rays were inconclusive (Fig. 3), and a CT scan (Fig. 2,4) was recommended but delayed for 6 days following neurosurgical consultation. During this period, the hematoma did not enlarge, and NIV NAVA settings were reduced. CT imaging eventually revealed a thin subdural hematoma and diastasis of the right coronal and lambdoid sutures. An MRI performed the following day showed no intracranial abnormalities (Fig. 5). The infant was weaned to room air and transitioned from TPN to oral feeding due to initial weight gain concerns. The patient was stable at discharge. Case Presentation

Acute cephalohematoma is relatively common, but the etiologies do not include the circumstances which led to our patient's injury. They can be due to pelvic pressure in labor, prolonged laboring, device-assisted delivery, and fetal macrosomia to name a few, but have rarely been documented due to trauma in utero. This is what makes this case stand out among fetal cephalohematoma cases. There has been no specific cases documented which display a case of fetal cephalohematoma due to a rapid deceleration in a motor vehicle accident causing the impact of the parietal bone with the mother's pelvic bone. The tachycardia and mild respiratory depression, although not usually correlated with cephalohematoma, would be an appropriate stress response given the traumatic circumstances of the injury. The anemia though is an expected and common secondary side effect of the cephalohematoma. All the above eventually resolved with improvement of the injury. Conclusions The unusual circumstances of this case highlight the importance of including fetal cephalohematoma in the differential diagnosis for pregnant individuals involved in traumatic accidents — particularly when fetal instability cannot be explained by other causes. Early detection is key, as it can not only prevent the progression to chronic cephalohematoma but also reduce the risk of associated complications.

Figure 1. Description and Visual Aid of Cephalohematoma

Figure 2. CT imaging revealing subdural hematoma

Figure 3. Skull X-ray showing suspected fracture

References

Figure 4. CT imaging displaying cephalohematoma

Figure 5. MRI imaging revealing cephalohematoma but not other intracranial abnormalities

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